Oriental Insurance Co. Ltd. vs RAMESH MARUTRAO JADHAV

THE State Commission of Maharashtra had passed an order dated the 3rd July, 1991 in Complaint Case No. 87 of 1990 in favour of the complainant before it and respondent herein directing the appellant, Oriental Insurance Company to finalise the claim of the complainant for Rs. 1,91,590.40Ps. and to pay Rs. 1,000/- as costs. THE appellant has challenged the order of the State Commission by way of this appeal, inter alia, on the ground that there was suppression of facts by the insured at the time of taking the insurance policy and as such it was entitled to repudiate the med-i-claim of the complainant under the policy.

THE facts of the case briefly are that the respondent /complainant had been insuring himself against accident as well as sickness risk since, 1965. In particular, he had obtained a med-i-claim policy valid for the period from 3.2.1987 to 2.2.1988. In November, 1987, the respondent/ complainant developed chest pain and had to undergo by-pass heart surgery. But the appellant, Insurance Company, did not entertain the claim and rejected the same on the ground that the respondent/complainant had not disclosed at the time of submitting the proposal of the insurance policy that he was suffering from Diabetes Millitus. THE surveyor had found that the respondent had been suffering from diabetes millitus for about 10 years and hypertension for about 6 years prior to the policy in question and that he failed to disclose the material facts in the proposal form. THE appellant in his appeal had emphasised that at the time of annual renewal of the policy the insured was required to furnish the relevant information in the proposal form. It was alleged that "the complainant failed to answer the said specific question (columns 10 and 11 of the Declaration in the proposal form) truthfully and did not disclose that he has been suffering from Diabetes Millitus for a period of about W years and hypertension". Consequently, the appellant repudiated the claim of the Respondent in April, 1989, inasmuch as there was nondisclosure of material facts. The State Commission in its order had observed that there was not an iota of evidence placed on record by the opposite party (insurer) either oral or documentary that the complainant received medication for diabetes millitus and hypertension. It observed that "When it is the case of the opposite party that the complainant received medication for the aforesaid ailment, it was the duty of the opposite party to establish the fact of such ailment by the complainant and the medication received by him by convincing evidence". It further remarked : "The proposal form for the said policy is attached in that prospectus. There is no such column like 10 and 11. The letter dated 19.4.1989 and the reasons stated therein to repudiate the claim of the complainant are absolutely false and frivolous. In the said letter there is a mention that the claim was referred to Shri P.A. Abhainkar for necessary investigation. No report of the investigation and no affidavit of the said Abhainkar is placed on record to establish the fact of non-disclosure of the missing material facts".

The correctness of these observations of the State Commission was challenged before us in Appeal. The appellant averred that the finding that the respondent/complainant was not suffering from diabetes and hypertension and had not received medication was contrary to the record. It was submitted before this Commission at the hearing of 11th February, 1993 that the State Commission was factually in error in stating in its order that no affidavit had been filed before it by Mr. Abhainkar who had been appointed by the insurance company to conduct survey of the claim and that the records of the hospital were also not produced before the State Commission. The Counsel for the Appellant asserted that these statements in the order of the State Commission were incorrect, and that the affidavit of Mr. Abhainkar, as well as medical records had been produced and filed before the State Commission.

IN view of these averments in the appeal petition and also in the submissions made by the Counsel for the appellant, it became necessary to call for the original records of the case from the State Commission to verify the correctness or otherwise of the submissions made in the appeal and by the appellant''s Counsel. At the hearing held on 26th April, 1993 the Counsel for the appellant stated that, after scrutiny of the record of the State Commission, he was unable to locate the affidavit of Mr. Abhainkar as well as the medical records said to have been produced before the State Commission. We find that the above averments made in the appeal on this point cannot be accepted as correct on the basis of the record of the State Commission.

WE also notice that in the papers submitted to this Commission by the Counsel for the appellant on 15th March, 1993 (pages 94 to 102 of the paper book), there is no mention that these records, now filed before this Commission, had been filed at any stage before the State Commission. In the light of the above facts, we have no doubt that the State Commission was justified in making the observations it had made in its order and coming to the adverse finding recorded in that order. The appeal is, therefore, dismissed and the order of the State Commission is confirmed. The appellant will pay a sum of Rs. 1,000/- by way of costs to the respondent. Appeal dismissed.